This document reviews the role of collagen membranes in alveolar bone grafting. It discusses how collagen membranes can be used in conjunction with autogenous bone grafts to reconstruct alveolar cleft defects. Collagen membranes act as a barrier to prevent soft tissue ingrowth and allow bone regeneration to occur without competition from soft tissues. Studies show collagen membranes lead to more new bone formation and less fibrous tissue compared to sites without membranes. The document examines different types of collagen membranes and their properties. In conclusion, using a resorbable collagen membrane with an autogenous bone graft provides superior results for alveolar ridge augmentation.

1. © 2019 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 745
Saudi Journal of Medical and Pharmaceutical Sciences
Abbreviated Key Title: Saudi J Med Pharm Sci
ISSN 2413-4929 (Print) |ISSN 2413-4910 (Online)
Scholars Middle East Publishers, Dubai, United Arab Emirates
Journal homepage: http://scholarsmepub.com/sjmps/
Review Article
Role of Collagen Membrane in Alveolar Bone Grafting - A Review
Dr. Kartheek Chinthala1*
, Dr. Ibadur Rahman Khan2
, Dr. Anuradha Uttam Lokare3
, Dr. Metla Subbaiah Naidu4
, Dr.
Vanka Aruna5
, Dr. Vedatrayi6
, Dr. Rahul Vinay Chandra Tiwari7
1
MDS; Consultant oral and maxillofacial surgeon, Kadapa, Andhra Pradesh, India
2
Consultant Oral and maxillofacial surgeon, Family dental care, 4-3-116/1 pillar no. 123 Attapur, Hyderabad, Telangana, India
3
MDS, Consultant Oral Pathologist, Mumbai, India
4
Consultant oral and maxillofacial surgeon and implantologist, Indo American dental hospital, Yosufgoda Road, opp state home ammerpet, Hyderabad
Telangana, India
5
Consultant Periodontist, FMS Dental Hospitals, Hyderabad, Telangana, India
6
MDS, Consultant Oral and Maxillofacial Surgeon, Tnagar Chennai, India
7
FOGS, MDS, Assistant Professor, Department of Oral and Maxillofacial Surgery, Sri Sai College of Dental Surgery, Vikarabad, India
DOI:10.21276/sjmps.2019.5.8.9 | Received: 08.08.2019 | Accepted: 19.08.2019 | Published: 30.08.2019
*Corresponding author: Dr. Kartheek Chinthala
Abstract
One of the most notable congenital malformations in the head and neck include cleft lip, palate & alveolus. It may
manifest as unilateral or bilateral and complete or incomplete. Reconstruction of the alveolar cleft is challenging and has
ever remained controversial with regard to timing, graft materials, surgical techniques, and methods of evaluation. The
primary goal of alveolar cleft reconstruction in is to provide a bony bridge at the cleft site that allows maxillary arch
continuity, oronasal fistula repair, eruption of the permanent dentition into the newly formed bone, enhances nasal
symmetry through providing alar base support, orthodontic movement and placement of osseointegrated implants when
indicated. In addition to these it also enhances speech, periodontal conditions, establishes better oral hygiene, and limits
growth disturbances. In order to rehabilitate oral function in patients with cleft lip and or palate, alveolar bone grafting is
necessary. Secondary bone grafting is the most widely accepted method for treating alveolar clefts. Literature shows that
autogenous bone graft is the primary source for reconstructing alveolar cleft defects and is currently the preferred
grafting material. However, it is believed that the use of a membrane in conjunction with an autogenous bone graft for
alveolar ridge augmentation provides superior results. Hence, this paper reviews the role of collagen membrane in
alveolar bone grafting.
Keywords: Collagen Membrane, surgical techniques, osseointegrated implants, alveolar bone grafting.
Copyright @ 2019: This is an open-access article distributed under the terms of the Creative Commons Attribution license which permits unrestricted
use, distribution, and reproduction in any medium for non-commercial use (NonCommercial, or CC-BY-NC) provided the original author and source
are credited.
INTRODUCTION
Clefts of the lip, palate, and alveolus are
considered to be one of the most common congenital
anomaly to affect the orofacial region [1]. These
patients have an esthetic as well as functional
imbalance. Repair of the cleft alveolus in particular is
an adjunctive procedure to improve the social wellbeing
of a patient with cleft lip and palate. It is generally
recommended during the mixed dentition period [2].
Alveolar bone graft is considered to be an essential step
in the overall management of a patient with cleft lip and
palate [3]. Alveolar cleft bone grafting aids in
facilitation of oral hygiene by modification of the
complex morphology of the alveolar cleft, induction of
canine eruption into the alveolar cleft, closure of
vestibular fistulae, stabilization of the arch form during
orthodontic treatment, creation of an alveolar bridge,
and improvement in facial morphology by elevation of
the alar base [1]. Fresh autogenous bone is generally
ideal for alveolar bone grafting since it provides living
immunocompatible bone cells essential to osteogenesis
for optimum osteoconductive, osteoinductive and
osteogenic properties. However, it is associated with the
need for surgery at donor site and the morbidity
associated with it [4]. The use of xenografts have
reduced the need for donor site morbidity. Materials
like deproteinized bovine bone mineral (DBBM) &
Bio-Oss collagen possesses osteoconductive and
biocompatibility properties [5]. Recently collagen
membrane is being used as a barrier membrane, where
the blood clot and the graft are stabilized, and the
epithelial and connective tissue cell migration is
avoided, and slow migrating osteogenic cells can
proliferate, resulting in new bone formation [6].

2. Kartheek Chinthala et al; Saudi J Med Pharm Sci, Aug 2019; 5(8): 745-747
© 2019 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 746
COLLAGEN MEMBRANE
Recently, the use of collagen membrane has
gained popularity in guided tissue regeneration (GTR)
and guided bone regeneration (GBR) [7]. Collagen
membrane is a biocompatible membrane, made from
types I and III collagen of porcine origin. GBR is a
technique that works on the principle of separating
particulate graft material from surrounding soft tissue to
allow for bone regeneration, which occurs at a slower
rate compared to soft tissues [8]. Collagen membranes
are frequently used to stabilize the graft material, limit
the graft resorption in addition to acting as an occlusive
barrier toward the surrounding soft tissue regeneration
and infiltration [9]. Bone resorption has been reported
in cases where autografts are used without membranes.
Therefore, membranes are utilized in nonspace making
bone defects that require space maintenance and
prevention of soft tissue ingrowth where bone
regeneration is required [10]. Collagen-based
membranes (CBMs) have similar permissive bone
formation capabilities when compared to non-
absorbable membranes [11]. They are classified as non-
cross-linked membranes and cross-linked membranes
depending on whether the cross-linking between the
collagen fibers was artificially increased. The use of
aldehyde and other chemical materials for covalent
bonding has been referred to as chemical cross-linking.
The natural behavior of the collagen membrane depends
on the type of material used for cross-linking [12]. The
amount and quality of the bone formed are similar
regardless of the collagen membrane, but the exposure
of the grafted bone to the oral environment during the
healing period cause a negative influence which is
prevented by the collagen sheet [13]. Collagen
membranes are composed of collagen, which occupies
majority of the normal tissue extracellular matrix, host
immune cells, fibroblasts, and endothelial cells migrate
through it and settle in and around it [14]. The use of
collagen membranes in alveolar grafting has increased
due to their high degree of biocompatibility and
resorbable nature. Animal studies have shown it to be
highly biocompatible, with no inflammatory cells
collected at the site of surgery [15]. It is known that an
autologous bone graft is replaced by new bone over a
period of time. This remodeling process is slow in
comparison to the regeneration and healing of the
adjacent soft tissue. The membrane excludes the soft
tissues, allowing remodeling to occur without any
unwanted soft tissue ingress into the bony defects [7].
Collagen membrane degrades completely in 4 to 6
months after placement. Within this time, both soft
tissue and bone get well integrated. In patients with
cleft alveolus, this should ensure good bony integration
of the underlying maxillary segment that is contiguous
with an uninterrupted overlying palatal mucosa. This
ensures that the recurrence of oronasal fistulas is
extremely unlikely. In the absence of a membrane, if
there was degradation of the bone graft, the ingress of
palatal/nasal mucosal tissue can occur leading to the
establishment of oronasal fistula. It is therefore
important that the entire bone graft be enclosed by the
membrane to protect the bone graft during remodeling
and incorporation into the cleft [7]. Verschueren et al.,
analyzed the healed bone radiographically and
histologically. This study showed that the membrane-
covered defects had a significantly reduced defect area
compared with the uncovered side. Histologically, the
covered side was seen to have more organized
osteogenesis and less fibrous tissue than the uncovered
defects had. Histomorphometry revealed the
membrane-covered sides to have significantly larger
defect-area fill than the uncovered side [16].
TYPES OF COLLAGEN MEMBRANE
Collagen-based materials have often been used
in alveolar grafting s because of the desirable material
properties of collagen like natural origin, rapid
biodegradation rate, biocompatibility, etc. To decrease
the degradation rate and enhance the temporal stability
of collagen-based membranes, manufacturers have used
several cross-linking approaches [17]. inspite of the fact
that cross-linking may address membrane stability in
the oral or wound environment, it may also result in
compromised attachment and proliferation of desirable
connective tissue wound cells which could lead to
delayed wound healing and possible infection as well as
to undesirable tissue reaction [15]. Alternative collagen
processing and membrane manufacturing techniques
have been developed which involves the combination of
non-cross-linked native collagen III, which undergoes
relatively fast degradation, and collagen I, which is
more resistant, in order to tightly control membrane
degradation [18]. The new non-cross-linked XCM is
composed of collagen type I and type III without further
cross-linking or chemical treatment. The XCM matrix
is a bilayer: one side is thin and smooth and is of low
porosity, while the other is a more porous 3-
dimensional network. The XCM must be placed with
the thin and smooth surface as the external layer since it
is designed to allow cell attachment and host tissue
integration but at the same time to remain impermeable
to invading cells for 30 days. The more porous part is
designed to be the internal layer since it is rapidly
infiltrated by host mesenchymal cells [18, 19].
CONCLUSION
Literature has shown that the use of a
resorbable collagen membrane in conjunction with an
autogenous bone graft and inorganic bovine mineral
(IBM) for alveolar ridge augmentation provides
superior results. The treatment of vertically deficient
alveolar ridges with guided bone regeneration using a
mixture of autogenous bone and DBBM and resorbable
collagen membrane can be considered successful, using
this technique in an out-patient office setting.

3. Kartheek Chinthala et al; Saudi J Med Pharm Sci, Aug 2019; 5(8): 745-747
© 2019 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 747
REFERENCES
1. Aly, L. A. A., & Hammouda, N. (2016).
Secondary closure of alveolar cleft with resorbable
collagen membrane and a combination of intraoral
autogenous bone graft and deproteinized
anorganic bovine bone. Annals of maxillofacial
surgery, 6(2), 165-171.
2. Boyne, P. J. (1972). Secondary bone grafting of
residual alveolar and palatal clefts. J Oral
Surg, 30, 87-92.
3. Epstein, L. I., Davis, W. B., & Thompson, L. W.
(1970). Delayed bone grafting in cleft palate
patients. Plastic and reconstructive surgery, 46(4),
363-367.
4. Walia, A. (2011). Secondary alveolar bone
grafting in cleft of the lip and palate
patients. Contemporary clinical dentistry, 2(3),
146-154.
5. Mokbel, N., Serhal, C. B., Matni, G., & Naaman,
N. (2008). Healing patterns of critical size bony
defects in rat following bone graft. Oral and
maxillofacial surgery, 12(2), 73-78.
6. Bernabé, P. F. E., Melo, L. G. N., Cintra, L. T. A.,
Gomes‐Filho, J. E., Dezan Jr, E., & Nagata, M. J.
H. (2012). Bone healing in critical‐size defects
treated with either bone graft, membrane, or a
combination of both materials: a histological and
histometric study in rat tibiae. Clinical oral
implants research, 23(3), 384-388.
7. Scott, J. K., Webb, R. M., & Flood, T. R. (2007).
Premaxillary osteotomy and guided tissue
regeneration in secondary bone grafting in
children with bilateral cleft lip and palate. The
Cleft Palate-Craniofacial Journal, 44(5), 469-475.
8. Buser, D., Dula, K., Hess, D., Hirt, H. P., &
Belser, U. C. (1999). Localized ridge
augmentation with autografts and barrier
membranes. Periodontology 2000, 19(1), 151-163.
9. Rakhmatia, Y. D., Ayukawa, Y., Furuhashi, A., &
Koyano, K. (2013). Current barrier membranes:
titanium mesh and other membranes for guided
bone regeneration in dental applications. Journal
of prosthodontic research, 57(1), 3-14.
10. Urban, I. A., Lozada, J. L., Jovanovic, S. A.,
Nagursky, H., & Nagy, K. (2014). Vertical ridge
augmentation with titanium-reinforced, dense-
PTFE membranes and a combination of
particulated autogenous bone and anorganic
bovine bone-derived mineral: a prospective case
series in 19 patients. International Journal of Oral
& Maxillofacial Implants, 29(1):185-93.
11. Schwarz, F., Rothamel, D., Herten, M., Sager, M.,
& Becker, J. (2006). Angiogenesis pattern of
native and cross‐linked collagen membranes: an
immunohistochemical study in the rat. Clinical
Oral Implants Research, 17(4), 403-409.
12. Delgado, L. M., Bayon, Y., Pandit, A., &
Zeugolis, D. I. (2015). To cross-link or not to
cross-link? Cross-linking associated foreign body
response of collagen-based devices. Tissue
Engineering Part B: Reviews, 21(3), 298-313.
13. Friedmann, A., Gissel, K., Soudan, M., Kleber, B.
M., Pitaru, S., & Dietrich, T. (2011). Randomized
controlled trial on lateral augmentation using two
collagen membranes: morphometric results on
mineralized tissue compound. Journal of clinical
periodontology, 38(7), 677-685.
14. Owens, K. W., & Yukna, R. A. (2001). Collagen
membrane resorption in dogs: a comparative
study. Implant dentistry, 10(1), 49-58.
15. Rothamel, D., Schwarz, F., Sculean, A., Herten,
M., Scherbaum, W., & Becker, J. (2004).
Biocompatibility of various collagen membranes
in cultures of human PDL fibroblasts and human
osteoblast‐like cells. Clinical Oral Implants
Research, 15(4), 443-449.
16. Verschueren, D. S., Gassner, R., Mitchell, R., &
Mooney, M. P. (2005). The effects of guided
tissue regeneration (GTR) on modified Le Fort I
osteotomy healing in rabbits. International journal
of oral and maxillofacial surgery, 34(6), 650-655.
17. Goissis, G., Junior, E. M., Marcantônio, R. A. C.,
Lia, R. C. C., Cancian, D. C., & de Carvalho, W.
M. (1999). Biocompatibility studies of anionic
collagen membranes with different degree of
glutaraldehyde cross-linking. Biomaterials, 20(1),
27-34.
18. Ghanaati, S., Schlee, M., Webber, M. J.,
Willershausen, I., Barbeck, M., Balic, E., ... &
Kirkpatrick, C. J. (2011). Evaluation of the tissue
reaction to a new bilayered collagen matrix in vivo
and its translation to the clinic. Biomedical
materials, 6(1), 015010.
19. Jung, R. E., Hürzeler, M. B., Thoma, D. S.,
Khraisat, A., & Hämmerle, C. H. (2011). Local
tolerance and efficiency of two prototype collagen
matrices to increase the width of keratinized
tissue. Journal of Clinical Periodontology, 38(2),
173-179.